Bronson South Haven Hospital

All Charges

Charge

Type

Setting

Price

PR ANESTHESIA C HYST W/O ANY LABOR ANALG/ANES CARE

Professional

Both

$8.00

Service Code	HCPCS 01963
Min. Negotiated Rate	$3.20
Max. Negotiated Rate	$6.00
Rate for Payer: BCBS Complete	$3.20
Rate for Payer: Cash Price	$6.40
Rate for Payer: Opus (Opus Packaging Group) HMA	$6.00

PR ANESTHESIA CLOSED CHEST PX NEEDLE BIOPSY PLEURA

Professional

Both

$4.00

Service Code	HCPCS 00522
Min. Negotiated Rate	$1.60
Max. Negotiated Rate	$3.00
Rate for Payer: BCBS Complete	$1.60
Rate for Payer: Cash Price	$3.20
Rate for Payer: Opus (Opus Packaging Group) HMA	$3.00

PR ANESTHESIA CLOSED CHEST PX PNEUMOCENTESIS

Professional

Both

$4.00

Service Code	HCPCS 00524
Min. Negotiated Rate	$1.60
Max. Negotiated Rate	$3.00
Rate for Payer: BCBS Complete	$1.60
Rate for Payer: Cash Price	$3.20
Rate for Payer: Opus (Opus Packaging Group) HMA	$3.00

PR ANESTHESIA CLOSED CHEST PX W/BRONCHOSCOPY NOS

Professional

Both

$6.00

Service Code	HCPCS 00520
Min. Negotiated Rate	$2.40
Max. Negotiated Rate	$4.50
Rate for Payer: BCBS Complete	$2.40
Rate for Payer: Cash Price	$4.80
Rate for Payer: Opus (Opus Packaging Group) HMA	$4.50

PR ANESTHESIA CLOSED PROCEDURES HUMERUS & ELBOW

Professional

Both

$3.00

Service Code	HCPCS 01730
Min. Negotiated Rate	$1.20
Max. Negotiated Rate	$2.25
Rate for Payer: BCBS Complete	$1.20
Rate for Payer: Cash Price	$2.40
Rate for Payer: Opus (Opus Packaging Group) HMA	$2.25

PR ANESTHESIA CLOSED PROCEDURES UPPER 2/3 FEMUR

Professional

Both

$4.00

Service Code	HCPCS 01220
Min. Negotiated Rate	$1.60
Max. Negotiated Rate	$3.00
Rate for Payer: BCBS Complete	$1.60
Rate for Payer: Cash Price	$3.20
Rate for Payer: Opus (Opus Packaging Group) HMA	$3.00

PR ANESTHESIA COMBINED UPPER&LOWER GI ENDOSCOPIC PX

Professional

Both

$1.00

Service Code	HCPCS 00813
Min. Negotiated Rate	$0.40
Max. Negotiated Rate	$0.75
Rate for Payer: BCBS Complete	$0.40
Rate for Payer: Cash Price	$0.80
Rate for Payer: Opus (Opus Packaging Group) HMA	$0.75

PR ANESTHESIA DIAGNOSTIC ARTERIOGRAPHY/VENOGRAPHY

Professional

Both

$5.00

Service Code	HCPCS 01916
Min. Negotiated Rate	$2.00
Max. Negotiated Rate	$3.75
Rate for Payer: BCBS Complete	$2.00
Rate for Payer: Cash Price	$4.00
Rate for Payer: Opus (Opus Packaging Group) HMA	$3.75

PR ANESTHESIA DIAGNOSTIC ARTHROSCOPIC PX KNEE JOINT

Professional

Both

$3.00

Service Code	HCPCS 01382
Min. Negotiated Rate	$1.20
Max. Negotiated Rate	$2.25
Rate for Payer: BCBS Complete	$1.20
Rate for Payer: Cash Price	$2.40
Rate for Payer: Opus (Opus Packaging Group) HMA	$2.25

PR ANESTHESIA DIAGNOSTIC ARTHROSCOPIC PX WRIST

Professional

Both

$3.00

Service Code	HCPCS 01829
Min. Negotiated Rate	$1.20
Max. Negotiated Rate	$2.25
Rate for Payer: BCBS Complete	$1.20
Rate for Payer: Cash Price	$2.40
Rate for Payer: Opus (Opus Packaging Group) HMA	$2.25

PR ANESTHESIA DX ARTHROSCOPIC PX ELBOW JOINT

Professional

Both

$3.00

Service Code	HCPCS 01732
Min. Negotiated Rate	$1.20
Max. Negotiated Rate	$2.25
Rate for Payer: BCBS Complete	$1.20
Rate for Payer: Cash Price	$2.40
Rate for Payer: Opus (Opus Packaging Group) HMA	$2.25

PR ANESTHESIA DX ARTHROSCOPIC PX SHOULDER JOINT

Professional

Both

$4.00

Service Code	HCPCS 01622
Min. Negotiated Rate	$1.60
Max. Negotiated Rate	$3.00
Rate for Payer: BCBS Complete	$1.60
Rate for Payer: Cash Price	$3.20
Rate for Payer: Opus (Opus Packaging Group) HMA	$3.00

PR ANESTHESIA ELECTROCONVULSIVE THERAPY

Professional

Both

$4.00

Service Code	HCPCS 00104
Min. Negotiated Rate	$1.60
Max. Negotiated Rate	$3.00
Rate for Payer: BCBS Complete	$1.60
Rate for Payer: Cash Price	$3.20
Rate for Payer: Opus (Opus Packaging Group) HMA	$3.00

PR ANESTHESIA EXTENSIVE SPINE&SPINAL CORD PROCEDURE

Professional

Both

$13.00

Service Code	HCPCS 00670
Min. Negotiated Rate	$5.20
Max. Negotiated Rate	$9.75
Rate for Payer: BCBS Complete	$5.20
Rate for Payer: Cash Price	$10.40
Rate for Payer: Opus (Opus Packaging Group) HMA	$9.75

PR ANESTHESIA EXTERNAL CEPHALIC VERSION

Professional

Both

$5.00

Service Code	HCPCS 01958
Min. Negotiated Rate	$2.00
Max. Negotiated Rate	$3.75
Rate for Payer: BCBS Complete	$2.00
Rate for Payer: Cash Price	$4.00
Rate for Payer: Opus (Opus Packaging Group) HMA	$3.75

PR ANESTHESIA EXTREME AGE PATIENT<1 YR&>70

Professional

Both

$101.00

Service Code	HCPCS 99100
Min. Negotiated Rate	$40.40
Max. Negotiated Rate	$75.75
Rate for Payer: Aetna Commercial	$52.00
Rate for Payer: BCBS Complete	$40.40
Rate for Payer: Cash Price	$80.80
Rate for Payer: Cash Price	$80.80
Rate for Payer: Opus (Opus Packaging Group) HMA	$75.75
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network	$50.00
Rate for Payer: Priority Health Narrow Network	$50.00

PR ANESTHESIA FOR ALL CLOSED PX INVOLVING HIP JOINT

Professional

Both

$4.00

Service Code	HCPCS 01200
Min. Negotiated Rate	$1.60
Max. Negotiated Rate	$3.00
Rate for Payer: BCBS Complete	$1.60
Rate for Payer: Cash Price	$3.20
Rate for Payer: Opus (Opus Packaging Group) HMA	$3.00

PR ANESTHESIA FOR PX MAJOR VESSELS NECK NOS

Professional

Both

$10.00

Service Code	HCPCS 00350
Min. Negotiated Rate	$4.00
Max. Negotiated Rate	$7.50
Rate for Payer: BCBS Complete	$4.00
Rate for Payer: Cash Price	$8.00
Rate for Payer: Opus (Opus Packaging Group) HMA	$7.50

PR ANESTHESIA FOR STERNAL DEBRIDEMENT

Professional

Both

$10.00

Service Code	HCPCS 00550
Min. Negotiated Rate	$4.00
Max. Negotiated Rate	$7.50
Rate for Payer: BCBS Complete	$4.00
Rate for Payer: Cash Price	$8.00
Rate for Payer: Opus (Opus Packaging Group) HMA	$7.50

PR ANESTHESIA GASTROCNEMIUS RECESSION

Professional

Both

$5.00

Service Code	HCPCS 01474
Min. Negotiated Rate	$2.00
Max. Negotiated Rate	$3.75
Rate for Payer: BCBS Complete	$2.00
Rate for Payer: Cash Price	$4.00
Rate for Payer: Opus (Opus Packaging Group) HMA	$3.75

PR ANESTHESIA HERNIA REPAIR LOWER ABDOMEN NOS

Professional

Both

$4.00

Service Code	HCPCS 00830
Min. Negotiated Rate	$1.60
Max. Negotiated Rate	$3.00
Rate for Payer: BCBS Complete	$1.60
Rate for Payer: Cash Price	$3.20
Rate for Payer: Opus (Opus Packaging Group) HMA	$3.00

PR ANESTHESIA HERNIA REPAIR UPPER ABDOMEN NOS

Professional

Both

$4.00

Service Code	HCPCS 00750
Min. Negotiated Rate	$1.60
Max. Negotiated Rate	$3.00
Rate for Payer: BCBS Complete	$1.60
Rate for Payer: Cash Price	$3.20
Rate for Payer: Opus (Opus Packaging Group) HMA	$3.00

PR ANESTHESIA INCOMPLETE/MISSED ABORTION PROCEDURES

Professional

Both

$4.00

Service Code	HCPCS 01965
Min. Negotiated Rate	$1.60
Max. Negotiated Rate	$3.00
Rate for Payer: BCBS Complete	$1.60
Rate for Payer: Cash Price	$3.20
Rate for Payer: Opus (Opus Packaging Group) HMA	$3.00

PR ANESTHESIA INDUCED ABORTION PROCEDURES

Professional

Both

$4.00

Service Code	HCPCS 01966
Min. Negotiated Rate	$1.60
Max. Negotiated Rate	$3.00
Rate for Payer: BCBS Complete	$1.60
Rate for Payer: Cash Price	$3.20
Rate for Payer: Opus (Opus Packaging Group) HMA	$3.00

PR ANESTHESIA INTERPELVIABDOMINAL AMPUTATION

Professional

Both

$15.00

Service Code	HCPCS 01140
Min. Negotiated Rate	$6.00
Max. Negotiated Rate	$11.25
Rate for Payer: BCBS Complete	$6.00
Rate for Payer: Cash Price	$12.00
Rate for Payer: Opus (Opus Packaging Group) HMA	$11.25

Know your out-of-pocket cost for care.

All Charges